National Survey of the Bone Densitometry Evaluation Process Within an Integrated Healthcare System.

BACKGROUND: To assess the current state of bone mineral density evaluation services via dual energy x-ray absorptiometry (DXA) provided to Veterans with fracture risk through the development and administration of a nationwide survey of facilities in the Veterans Health Administration. METHODOLOGY: The Bone Densitometry Survey was developed by convening a Work Group of individuals with expertise in bone densitometry and engaging the Work Group in an iterative drafting and revision process. Once completed, the survey was beta tested, administered through REDCap, and sent via e-mail to points of contact at 178 VHA facilities. RESULTS: Facility response rate was 31 % (56/178). Most DXA centers reported positively to markers of readiness for their bone densitometers: less than 10 years old (n=35; 63 %); in "excellent" or "good" condition (n=44; 78 %, 32 % and 46 %, respectively); and perform phantom calibration (n=43; 77 %). Forty-one DXA centers (73 %) use intake processes that have been shown to reduce errors. Thirty-seven DXA centers (66 %) reported their technologists receive specialized training in DXA, while 14 (25 %) indicated they receive accredited training. Seventeen DXA centers (30 %) reported performing routine precision assessment. CONCLUSIONS: Many DXA centers reported using practices that meet minimal standards for DXA reporting and preparation; however, the lack of standardization, even within an integrated healthcare system, indicates an opportunity for quality improvement to ensure consistent high quality bone mineral density evaluation of Veterans.

Cultivating across "pockets of excellence": challenges to sustaining efforts to improve osteoporosis care.

We conducted in-depth, semi-structured interviews with clinicians involved in bone health care to understand the challenges of implementing and sustaining bone health care interventions. Participants identified individual- and system-level challenges to care delivery, implementation, and sustainment. We discuss opportunities to address challenges through a commitment to relationship- and infrastructure-building support. PURPOSE: Osteoporosis and fracture-related sequalae exact significant individual and societal costs; however, identification and treatment of at-risk patients are troublingly low, especially among men. The purpose of this study was to identify challenges to implementing and sustaining bone health care delivery interventions in the Veterans Health Administration. METHODS: We conducted interviews with endocrinologists, pharmacists, primary care physicians, rheumatologists, and orthopedic surgeons involved in bone health care (n = 20). Interviews were audio-recorded and transcribed verbatim. To determine thematic domains, we engaged in an iterative, qualitative content analysis of the transcripts. RESULTS: Participants reported multiple barriers to delivering bone health care and to sustaining the initiatives designed to address delivery challenges. Challenges of bone health care delivery existed at both the individual level-a lack of patient and clinician awareness and competing clinical demands-and the system level-multiple points of entry to bone health care, a dispersion of patient management, and guideline variability. To address the challenges, participants developed initiatives targeting the identification of at-risk patients, clinician education, increasing communication, and care coordination. Sustaining initiatives, however, was challenged by staff turnover and the inability to achieve and maintain priority status for bone health care. CONCLUSION: The multiple, multi-level barriers to bone health care affect both care delivery processes and sustainment of initiatives to improve those processes. Barriers to care delivery, while tempered by intervention, are entangled and persist alongside sustainment challenges. These challenges require relationship- and infrastructure-building support.

Health-related quality of life in head and neck cancer survivors: Evaluating the rural disadvantage.

PURPOSE: Head and neck cancer (HNC) survivors often experience distress and health-related quality of life (HRQOL) impairment. Research suggests that rural cancer patients may have poorer outcomes than urban patients. This study examined whether HNC patient emotional and HRQOL outcomes differ in those living in a rural versus urban location at 6 and 12 months postdiagnosis. METHODS: A total of 261 HNC patients were included from a longitudinal study of HNC outcomes. The majority were diagnosed with advanced stage cancer (51.3%); the most common cancer site was oral cavity (41.0%). Rurality was measured using the US Department of Agriculture Rural Urban Commuting Area codes. Depression was measured using the Beck Depression Inventory (BDI), general HRQOL using the Short Form-36 (SF-36), and HNC-specific HRQOL using the Head and Neck Cancer Inventory (HNCI). Analyses were 2 (group) × 3 (assessment) repeated measures ANCOVAs, controlling for demographic and clinical characteristics. FINDINGS: Approximately 45% of the sample lived in a rural location. Follow-up comparisons of significant overall models indicated that rural patients reported significantly more nonsomatic depression symptoms at 6-month follow-up. Rural patients were also more likely to report significantly poorer general mental HRQOL at 12-month follow-up, significantly poorer HNC-specific HRQOL related to eating at 6- and 12-month follow-up, and marginally worse aesthetics at 12-month follow-up. CONCLUSIONS: These findings are consistent with suggestions that rural HNC patients may be at heightened risk for depression symptoms and decrements in HRQOL. Patients should be screened and regularly monitored for issues with depression and HNC-specific HRQOL throughout the survivorship period.

Attitudes toward bone health among rural-dwelling veterans identified as at risk of fracture: a qualitative analysis.

Although much is known about system-level barriers to prevention and treatment of bone health problems, little is known about patient-level barriers. The objective of this study was to identify factors limiting engagement in bone health care from the perspective of rural-dwelling patients with known untreated risk. Over 6 months, 39 patients completed a qualitative interview. Interview questions focused on the patient's experience of care, their decision to not accept care, as well as their knowledge of osteoporosis and the impact it has had on their lives. Participants were well-informed and could adequately describe osteoporosis and its deleterious effects, and their decision making around accepting or declining a dual-energy x-ray absorptiometry (DXA) scan and treatment was both cautious and intentional. Decisions about how to engage in treatment were tempered by expectations for quality of life. Our findings suggest that people hold beliefs about bone health treatment that we can build on. Work to improve care of this population needs to recognize that bone health providers are not adding a behavior of medication taking to patients, they are changing a behavior or belief. Published 2021. This article is a U.S. Government work and is in the public domain in the USA. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Delivering fracture prevention services to rural US veterans through telemedicine: a process evaluation.

An informatics-driven population bone health clinic was implemented to identify, screen, and treat rural US Veterans at risk for osteoporosis. We report the results of our implementation process evaluation which demonstrated BHT to be a feasible telehealth model for delivering preventative osteoporosis services in this setting. PURPOSE: An established and growing quality gap in osteoporosis evaluation and treatment of at-risk patients has yet to be met with corresponding clinical care models addressing osteoporosis primary prevention. The rural bone health tea m (BHT) was implemented to identify, screen, and treat rural Veterans lacking evidence of bone health care and we conducted a process evaluation to understand BHT implementation feasibility. METHODS: For this evaluation, we defined the primary outcome as the number of Veterans evaluated with DXA and a secondary outcome as the number of Veterans who initiated prescription therapy to reduce fracture risk. Outcomes were measured over a 15-month period and analyzed descriptively. Qualitative data to understand successful implementation were collected concurrently by conducting interviews with clinical personnel interacting with BHT and BHT staff and observations of BHT implementation processes at three site visits using the Promoting Action on Research Implementation in Health Services (PARIHS) framework. RESULTS: Of 4500 at-risk, rural Veterans offered osteoporosis screening, 1081 (24%) completed screening, and of these, 37% had normal bone density, 48% osteopenia, and 15% osteoporosis. Among Veterans with pharmacotherapy indications, 90% initiated therapy. Qualitative analyses identified barriers of rural geography, rural population characteristics, and the infrastructural resource requirement. Data infrastructure, evidence base for care delivery, stakeholder buy-in, formal and informal facilitator engagement, and focus on teamwork were identified as facilitators of implementation success. CONCLUSION: The BHT is a feasible population telehealth model for delivering preventative osteoporosis care to rural Veterans.

Problem alcohol use among rural head and neck cancer patients at diagnosis: Associations with health-related quality of life.

OBJECTIVE: Problem alcohol use in persons with head and neck cancer (HNC) is associated with poor outcomes, including survival. Some evidence suggests that individuals living in rural areas may be at greater risk of problem alcohol use. The present exploratory cross-sectional study sought to examine problem alcohol use at diagnosis in a sample of HNC patients by rural versus urban status. METHODS: Self-reported problem alcohol use as measured by the Short Michigan Alcoholism Screening Test (SMAST) was examined in rural and urban HNC patients at diagnosis (N = 454). Multivariable linear regression analysis was conducted to examine correlates of problem alcohol use. Subgroup analyses examined HNC-specific health-related quality of life (HRQOL) by problem drinking status at diagnosis and 3- and 12-month postdiagnosis in rural patients. RESULTS: Multivariable linear regression analysis controlling for age, cancer site, cancer stage, depressive symptoms at diagnosis, and tobacco use at diagnosis indicated that rural residence was significantly associated with SMAST scores at diagnosis such that rural patients were more likely to report higher scores (ß = 0.095, sr2  = 0.010, p = 0.04). Covariate-adjusted subgroup analyses suggest that rural patients with self-reported problem alcohol use may exhibit deficits in HNC-specific HRQOL at diagnosis and 3- and 12-month postdiagnosis. CONCLUSIONS: HNC patients should be screened for problem alcohol use at diagnosis and counseled regarding the deleterious effects of continued drinking during treatment and beyond. Because access to treatment and referral options may be lacking in rural areas, additional ways of connecting rural patients to specialty care should be explored.

Longitudinal Case Series of Staphylococcus aureus Colonization and Infection in Two Cohorts of Rural Iowans.

OBJECTIVE: Examine the relationship between colonization with Staphylococcus aureus in the community and symptomatic infection in two cohorts of Iowans. DESIGN: Case series within cohort study. PARTICIPANTS: Rural Iowans selected from the Keokuk Rural Health Study, the Agricultural Health Study, and the Iowa Voter Registry. METHODS: Longitudinal study within established cohorts evaluating documented S. aureus infections with samples available for molecular typing. RESULTS: We examined this relationship in two cohorts of Iowans with a combined 11 incident cases of S. aureus SSTI, for which samples were available. Seven of the 11 individuals (63.6%) were colonized at baseline, in the nose (3/7, 42.9%), or in both the nose and throat (57.1%). All seven cases had matching sequence types between colonization and infection isolates. CONCLUSIONS: Staphylococcus aureus causes millions of skin and soft tissue infections yearly. Although colonization with S. aureus is a frequent antecedent to infection, many studies investigating the link between colonization and infection have taken place in a clinical setting, particularly in urban hospitals. Our study has shown similar results in a rural community setting to those previously seen in clinics.

Whole-Genome Analysis of Recurrent Staphylococcus aureus t571/ST398 Infection in Farmer, Iowa, USA.

Staphylococcus aureus strain sequence type (ST) 398 has emerged during the last decade, largely among persons who have contact with swine or other livestock. Although colonization with ST398 is common in livestock workers, infections are not frequently documented. We report recurrent ST398-IIa infection in an Iowa farmer in contact with swine and cattle.

Development and Validation of a Novel Acute Myeloid Leukemia-Composite Model to Estimate Risks of Mortality.

Importance: To our knowledge, this multicenter analysis is the first to test and validate (1) the prognostic impact of comorbidities on 1-year mortality after initial therapy of acute myeloid leukemia (AML) and (2) a novel, risk-stratifying composite model incorporating comorbidities, age, and cytogenetic and molecular risks. Objective: To accurately estimate risks of mortality by developing and validating a composite model that combines the most significant patient-specific and AML-specific features. Design, Setting, and Participants: This is a retrospective cohort study. A series of comorbidities, including those already incorporated into the hematopoietic cell transplantation­comorbidity index (HCT-CI), were evaluated. Patients were randomly divided into a training set (n = 733) and a validation set (n = 367). In the training set, covariates associated with 1-year overall mortality at a significance level of P < .10 constructed a multivariate Cox proportional hazards model in which the impact of each covariate was adjusted for that of all others. Then, the adjusted hazard ratios were used as weights. Performances of models were compared using C statistics for continuous outcomes and area under the curve (AUC) for binary outcomes. Exposures: Initial therapy for AML. Main Outcomes and Measures: Death within 1 year after initial therapy for AML. Results: A total of 1100 patients, ages 20 to 89 years, were treated for AML between January 1, 2008, and December 31, 2012, at 5 academic institutions specialized in treating AML; 605 (55%) were male, and 495 (45%) were female. In the validation set, the original HCT-CI had better C statistic and AUC estimates compared with the AML comorbidity index for prediction of 1-year mortality. Augmenting the original HCT-CI with 3 independently significant comorbidities, hypoalbuminemia, thrombocytopenia, and high lactate dehydrogenase level, yielded a better C statistic of 0.66 and AUC of 0.69 for 1-year mortality. A composite model comprising augmented HCT-CI, age, and cytogenetic/molecular risks had even better predictive estimates of 0.72 and 0.76, respectively. Conclusions and Relevance: In this cohort study, comorbidities influenced 1-year survival of patients with AML, and comorbidities are best captured by an augmented HCT-CI. The augmented HCT-CI, age, and cytogenetic/molecular risks could be combined into an AML composite model that could guide treatment decision-making and trial design in AML. Studying physical, cognitive, and social health might further clarify the prognostic role of aging. Targeting comorbidities with interventions alongside specific AML therapy might improve survival.

Prevalence and molecular characterization of Staphylococcus aureus in commercially available meat over a one-year period in Iowa, USA.

Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of infectious disease morbidity and mortality. Previous studies have confirmed the presence of S. aureus, including MRSA, on raw meat products. We investigated the prevalence and molecular epidemiology of S. aureus and MRSA in commercially-distributed antibiotic-free and conventional raw meat products (n = 3290) purchased in 8 Iowa retail stores weekly for a period of one year. Isolates were characterized using spa typing, and PCR was used to detect the presence of the Panton-Valentine leukocidin (PVL) and mecA genes. Quantitation of S. aureus on meat products was carried out one week per month. The prevalence of S. aureus on meat samples was 27.8% (913/3290). Compared to antibiotic-free meat samples, higher prevalence of both MRSA and methicillin-susceptible S. aureus (MSSA) were found in conventional meat samples. Among the S. aureus isolates, 18 were PVL-positive (1.9%) and 41 (4.5%) carried mecA. Phenotypic oxacillin resistance was observed for 17.1% (41/239) of the isolates tested, while 23% (55/239) were multi-drug resistant. A total of 132 spa types were detected from 913 contaminated meat samples. Overall, t002 was the most common spa type identified (137; 15.0%). The number of colony-forming units (CFU) per 10 g meat ranged from 2 to 517 (median: 8 CFU per 10 g of meat; mean: 28) with the highest bacterial load observed on turkey samples. These data reinforce the need to consider meat products as potential vehicles of S. aureus transmission from farm into human households, and the potential need for public health intervention programs pre and post-slaughter in meat processing facilities.

A Novel Methicillin-Resistant Staphylococcus aureus t11469 and a Poultry Endemic Strain t002 (ST5) Are Present in Chicken in Ebonyi State, Nigeria.

BACKGROUND: The changing epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) from a hospital-associated pathogen to an organism commonly found in the community and in livestock reflects an organism well-equipped to survive in diverse environments and adjust to different environmental conditions including antimicrobial use. METHODS: We investigated the molecular epidemiology of S. aureus and MRSA in poultry in Ebonyi State, Nigeria. Samples were collected from 1800 birds on 9 different farms within the state. Positive isolates were tested for antibiotic susceptibility and molecular typing. RESULTS: Prevalence in birds was 13.7% (247/1800). MRSA prevalence in poultry was 0.8%. The prevalence of MRSA in broilers and layers was 1.2% and 0.4%, respectively. All tested isolates were susceptible to vancomycin. Molecular analysis of the isolates revealed 3 spa types: t002, t084, and a novel spa type, t11469. The novel spa type t11469 belonged to sequence type ST5. CONCLUSION: The detection of t002 in chicken suggests the presence of livestock-associated MRSA in poultry in Ebonyi State. The detection of the new spa type t11469 in poultry that has not been characterised to ascertain its pathogenic potential remains a cause for concern, especially as some were found to carry PVL genes, a putative virulence factor in staphylococcal infection.

Prospective multicenter surveillance identifies Staphylococcus aureus infections caused by livestock-associated strains in an agricultural state.

We conducted a surveillance study to investigate the epidemiology of Staphylococcus aureus infections in Iowa, using a convenience sample. Diagnostic laboratories submitted 20 S. aureus isolates per month for a 20-month period between 2011 and 2013. Of the 2226 isolates analyzed, 73.6% were methicillin-resistant S. aureus (MRSA) and 26.4% were methicillin-susceptible S. aureus (MSSA). S. aureus infections in 25 patients (1%) were caused by ST398- and ST9-associated strain types, and appeared to be a common occurrence in areas of the state with the highest numbers of hogs and hog farms. Twenty nine (5.1%) of MSSA isolates and 10 (40.0%) livestock-associated strains were multi-drug resistant.

Detection of Airborne Methicillin-Resistant Staphylococcus aureus Inside and Downwind of a Swine Building, and in Animal Feed: Potential Occupational, Animal Health, and Environmental Implications.

Aerosolized methicillin-resistant Staphylococcus aureus (MRSA) was sampled inside and downwind of a swine facility. Animal feed was sampled before and after entry into the swine facility. Aerosolized particles were detected using an optical particle counter for real-time measurement and with an Andersen sampler to detect viable MRSA. Molecular typing and antimicrobial susceptibility testing were performed on samples collected. Viable MRSA organisms isolated inside the swine facility were primarily associated with particles >5 µm, and those isolated downwind from the swine facility were associated with particles <5 µm. MRSA isolates included spa types t008, t034, and t5706 and were resistant to methicillin, tetracycline, clindamycin, and erythromycin. Animal feed both before and after entry into the swine facility tested positive for viable MRSA. These isolates were of similar spa types as the airborne MRSA organisms. Air samples collected after power washing with a biocide inside the swine facility resulted in no viable MRSA organisms detected. This pilot study showed that the ecology of MRSA is complex. Additional studies are warranted on the maximum distance that viable MRSA can be emitted outside the facility, and the possibility that animal feed may be a source of contamination.

Human Infections with Staphylococcus aureus CC398.

Staphylococcus aureus isolates belonging to clonal cluster 398 (CC398) have emerged over the previous decade as a risk to livestock workers. Though most of the research to date has focused on colonization with these strains, a number of infections have also been documented, ranging from mild skin infections to more serious invasive infections and even death. Here, we review existing reports of human infections with CC398 and discuss their geographic distribution, general characteristics, and implications for future research. We identified 74 publications describing CC398 infections in humans in 19 different countries, suggesting this is an emerging worldwide issue.

Epidemiology of necrotizing infection caused by Staphylococcus aureus and Streptococcus pyogenes at an Iowa hospital.

The present study was performed to characterize the epidemiology of necrotizing soft tissue infection caused by Streptococcus pyogenes (n=14) and Staphylococcus aureus (n=14) isolates collected at the University of Iowa Hospitals and Clinics. An additional 9 S. pyogenes isolates were collected from patients being treated for mild respiratory infections and served as a comparison sample in the analysis. Patient data corresponding to the isolates (n=37) were also collected in order to identify risk factors or comorbid conditions possibly correlated with necrotizing fasciitis (NF). The prevalence of methicillin-resistant S. aureus among the study isolates was 35.7% (5/14), and the prevalence of the Panton-Valentine leukocidin (PVL) gene was 57% (8/14). The S. pyogenes NF (wound) isolates (n=14) belonged to 10 different emm types, none of which appeared to be associated with more severe disease when compared to the milder infection (throat) samples (n=9). Comorbid conditions such as diabetes and cardiovascular disease were significantly associated with NF. The results indicate that there may be a high prevalence of the PVL virulence factor in NF infections and that spa type t008 may be responsible for the increasing incidence of S. aureus NF infections in Iowa.

Swine Farming Is a Risk Factor for Infection With and High Prevalence of Carriage of Multidrug-Resistant Staphylococcus aureus.

BACKGROUND: Livestock-associated Staphylococcus aureus (LA-SA) has been documented worldwide. However, much remains unknown about LA-SA colonization and infection, especially in rural environments. METHODS: We conducted a large-scale prospective study of 1342 Iowans, including individuals with livestock contact and a community-based comparison group. Nasal and throat swabs were collected to determine colonization at enrollment, and skin infection swabs over 17 months were assessed for S. aureus. Outcomes included carriage of S. aureus, methicillin-resistant S. aureus (MRSA), tetracycline-resistant S. aureus (TRSA), multidrug-resistant S. aureus (MDRSA), and LA-SA. RESULTS: Of 1342 participants, 351 (26.2%; 95% confidence interval [CI], 23.8%-28.6%) carried S. aureus. MRSA was isolated from 34 (2.5%; 95% CI, 1.8%-3.5%) and LA-SA from 131 (9.8%; 95% CI, 8.3%-11.5%) of the 1342 participants. Individuals with current swine exposure were significantly more likely to carry S. aureus (prevalence ratio [PR], 1.8; 95% CI, 1.4-2.2), TRSA (PR, 8.4; 95% CI, 5.6-12.6), MDRSA (PR, 6.1; 95% CI, 3.8-10.0), and LA-SA (PR, 5.8; 95% CI, 3.9-8.4) than those lacking exposure. Skin infections (n = 103) were reported from 67 individuals, yielding an incidence rate of 6.6 (95% CI, 4.9-8.9) per 1000 person-months. CONCLUSIONS: Current swine workers are 6 times more likely to carry MDRSA than those without current swine exposure. We observed active infections caused by LA-SA. This finding suggests that individuals with livestock contact may have a high prevalence of exposure to, and potentially infection with, antibiotic-resistant S. aureus strains, including LA-SA strains.

Methicillin-resistant Staphylococcus aureus in central Iowa wildlife.

Livestock and pets have been identified as carriers of Staphylococcus aureus; however, the role of wild animals as a reservoir of S. aureus strains has not yet been examined. We conducted a pilot study to determine the prevalence of methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) in 37 species of wild animals rehabilitated at a university clinic. Nasal, wing, wound, and cloacal swabs were collected. Of 114 animals, seven (6.1%) were MSSA-positive and three (2.6%) were MRSA-positive. The MRSA isolates were obtained from two eastern cottontail rabbits (Sylvilagus floridanus) and a Lesser Yellowlegs (Tringa flavipes), a migratory shorebird. Antibiotic resistance testing of the MRSA isolates revealed that two were additionally resistant to tetracycline and erythromycin, and the third isolate was also resistant to erythromycin, clindamycin, and levofloxacin. All three isolates were positive for the Panton-Valentine leukocidin (PVL) gene. Sequence typing of the staphylococcal protein A (spa) region revealed one MRSA isolate to be t002, whereas the other two MRSA isolates were found to be t008. Our results suggest that S. aureus, including MRSA, is being carried by wild animals, although at a low prevalence with the limited number of animals tested. Additional studies are needed to determine how this may impact human health.

High prevalence of Panton-Valentine leukocidin among methicillin-sensitive Staphylococcus aureus colonization isolates in rural Iowa.

Recent studies have shown that livestock can carry Staphylococcus aureus and transmit it to human caretakers. We conducted a pilot study to determine the prevalence and molecular epidemiology of S. aureus among rural Iowans, including individuals with livestock contact. Nasal and throat swabs were collected and plated onto selective media to isolate methicillin-susceptible and methicillin-resistant S. aureus (MRSA), followed by antibiotic resistance testing and molecular analysis of the isolates. While no MRSA was detected, overall, 23.7% (31/131) of participants were found to harbor S. aureus in their nose, throat, or both. Fifteen isolates displayed resistance to one or more tested antibiotics, and the Panton-Valentine leukocidin (PVL) genes were present at a high level (29% [9/31] of S. aureus-positive participants). Younger age and tobacco use were associated with increased risk of S. aureus carriage. Our results suggest that carriage of PVL-positive S. aureus is common among rural Iowans, even in the absence of detectable MRSA colonization.